Request a Physical Therapy Appointment

If you are a new patient, please complete the form below for the location of your choice. A staff member will contact you within 24-48 business hours to schedule an appointment. If you are a current patient, please contact the clinic directly by phone to schedule an appointment. (*required)

First Name*

Last Name*

I am submitting this appointment request for my partner, child, parent or friend.

Their name*

Their Date of Birth*

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DD

YYYY

Email*

Phone*

Your Date of Birth*

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DD

YYYY

State*

Zip Code*

Clinic Location:*

I have a prescription from my doctor for:*

Physical Therapy
Occupational/Hand Therapy
I do not have a prescription

*You may be able to receive services without a prescription from your doctor. Our team will inform you when they contact you about your appointment.

*Now in Illinois, you no longer need a prescription for physical therapy.

*You no longer need a prescription for physical therapy.

Please list your doctor’s name*

Message/Best Time and Day to Contact*

Intake Paperwork

Other than a referring doctor, how did you hear about us?*

Please specify the name of the individual, event, organization or group*

By clicking this box you agree to receive email communication regarding appointment updates and marketing communication from Athletico Physical Therapy.

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Comments

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